Conducting a Pediatric Concussion Evaluation

Pediatric exams: Concussion evaluation

Christina Master, MD: Hi I’m Dr. Christina Master. I’m one of the sports medicine physicians and one of the co-directors of the Minds Matter Concussion Program here at The Children’s Hospital of Philadelphia. We see a lot of concussions in children here at The Children’s Hospital and we’re sure that you do as well. We’d like to share with you a lot of the new information that we’re learning and update you on how to best diagnosis and identify concussions in children in your practice.

I’d like to introduce you to Ava. She’s one of our patients who’s had a couple of concussions from sports. She plays ice hockey. She’s completely recovered now, but she’s agreed to help us demonstrate the physical exam and the history that we would be taking to help you identify concussions in your practice.

All right Ava, so tell me about your last concussion.

Ava, Patient: It happened about a month ago.

Christina Master, MD: OK, tell me a little bit about how it happened.

Ava, Patient: I was going into a corner with a kid that who bigger than me and he hit me from behind.

Christina Master, MD: OK, and did you have symptoms right away?

Ava, Patient: No.

Christina Master, MD: OK, when did you start to have symptoms and start to wonder that maybe you had a concussion?

Ava, Patient: The next day.

Christina Master, MD: OK, and what were those symptoms?

Ava, Patient: I was feeling nausea. I had a headache and sensitivity to light.

Christina Master, MD: OK, and you were able to finish the game without any problems?

Ava, Patient: Yes.

Christina Master, MD: OK, did you go to school the next day?

Ava, Patient: Yes.

Christina Master, MD: OK, what happened at school?

Ava, Patient: I couldn’t focus, my head hurt.

Christina Master, MD: When did you start to think that you had a concussion?

Ava, Patient: That night.

Christina Master, MD: OK, and at that point did you seek care with anybody else?

Ava, Patient: My mom.

Christina Master, MD: OK, all right. And that’s when you decided to call and get an appointment to come in. All right, and were you continuing to do homework?

Ava, Patient: Yes.

Christina Master, MD: And how about spending time on your cell phone or a desktop computer?

Ava, Patient: Yes.

Christina Master, MD: And how did those make you feel?

Ava, Patient: They made my head hurt.

Christina Master, MD: OK, have you done any exercise since you had your injury?

Ava, Patient: No.

Christina Master, MD: OK, and then after resting for a bit at home, did that help you symptoms a little?

Ava, Patient: Yes.

Christina Master, MD: OK, in addition to the history of the current concussion, we’d also like to get some past information on her. We usually like to find out how she’s done in school prior to this. What were her grades before her injury? We also like to find out in her history, or in her family, does anybody have ADHD, dyslexia, or a learning disability. Because these are some factors that can sometimes complicate the recover.

In addition, we like to ask if there’s any history of migraines, anxiety or depression. In particular, we’re also realizing now that it’s important to find out if there’s any visual disturbance in the family. Whether or not she wears glasses, and is nearsighted or farsighted. Or if there’s any history in the family, or in Ava, of strabismus, amblyopia, eye surgery, or eye patching for any kind of lazy eye kind of phenomenon.

We also like to know if there’s any history of motion sickness because of vestibular system can often being effected after concussion. And a sign of motion sickness in the car may indicate they may have more of those symptoms after a concussion.

All right, so Ava I want you to take a look at my finger. Follow my finger with your eyes. Don’t move your head. We’ll start slowly and go faster. Let me know if it gives you any symptoms, otherwise if it doesn’t give you any symptoms, we’ll keep going, OK? All right. As you can see Ava is doing a great job following my finger. And as we go faster, she’s able to keep up. She doesn’t have any problems with any symptoms. She’s not blinking or having her eyes water excessively, or complaining of headache or dizziness.

Just to note, when you track sometimes you can have a few beat of a nystagmus at the end, gaze, like she has here, that’s normal. But when you come to the middle, she locks in nice and solid and there’s no nystagmus in the central gaze. This is the smooth pursuit portion of the exam.

Now Ava, I want you to hold your head still. I want you to look at my fingers left right, left right as fast as you can until it gives you symptoms or I tell you to stop, OK? Go ahead. Now as you can see Ava’s performing the horizontal saccades. She’s going nice and smoothly. It’s not fatiguing, it’s not tired. She’s not blinking or stopping because she’s having headache or dizziness.

Often times when kids are acutely symptomatic, they will have trouble with this movement. What happens is they’ll often have their eyes start to water, or they’ll blink, or they’ll stop and they say that they either have headache or dizziness provoked by this maneuver.

Let’s do it up and down now, Ava. Up and down, keep your head still, look at both of my fingers as fast as you can. So again, as you can see, Ava is not having any symptoms. She’s not having any watering of her eyes. Her eyes are not fatiguing. She’s not blinking or stopping because she has dizziness or headache. But often what we’ll do is also ask the kids. Did that cause any dizziness or headache, Ava?

Ava, Patient: No.

Christina Master, MD: Great, wonderful, all right. Take a look at my thumb. I want you to focus on my thumb. And then I want you to bounce, and keep bouncing and let me know when that starts to give you any headache or dizziness, or bother you at all. Otherwise, we’ll keep going and I’ll tell you when to stop. This is the vertical vestibulo-ocular reflex, or gaze stability testing. All right you can stop, Ava. That looks great. When kids have symptoms with this, they’ll often stop or they won’t be able to do it quite as rapidly. Often, they can have their eyes start to water, or they’ll complain of worsening headache or dizziness.

Now we’ll do the horizontal vestibulo-ocular reflex. Focus on my finger. Shake your head side to side, and keep going until I tell you to stop or if it gives you symptoms. Great, did that give you any symptoms at all, headache or dizziness?

Ava, Patient: Nope.

Christina Master, MD: Great, wonderful. So now we’re gonna measure some binocular vision function. In particular, we’re interest in convergence. And this ruler is called a convergence rule. You can purchase this, it’s a specialty piece of equipment used by developmental optometrist. If you don’t have access to a convergence rule, you can also us a pen, and have the patient bring it close to their face, and their nose, to estimate what they’re convergence is in the same manner.

We’re going to have her take a look at the letters on this card. We’re going to ask her when they become blurry and when the line becomes double. And that will give us a sense of where her convergence point is. Ava take a look at the letters on the card, are they clear?

Ava, Patient: Yep.

Christina Master, MD: Great, tell me when they get blurry.

Ava, Patient: Blurry.

Christina Master, MD: Tell me when they become double.

Ava, Patient: Double.

Christina Master, MD: Tell me when it’s single again.

Ava, Patient: Single.

Christina Master, MD: Tell me when it’s clear again.

Ava, Patient: Clear.

Christina Master, MD: Great, and then now we’re gonna measure her accommodation. Cover your left eye, this is single eye accommodation. Are those letters clear?

Ava, Patient: Yep.

Christina Master, MD: Tell me when they get blurry.

Ava, Patient: Blurry.

Christina Master, MD: And then cover your right eye. Are those letter clear?

Ava, Patient: Yes.

Christina Master, MD: Tell me when they’re blurry.

Ava, Patient: They’re blurry.

Christina Master, MD: Great, so we would record all of those numbers for convergence and accommodation and track that over time as she recovers. In general kids should be able to converge less than 6 cm, and we would expect that to be normal.

Lastly, we’ll take a look at your balance. We’re going to step out into the hallway. I’d like you to walk heel toe, heel toe like you’re on a tight rope. And we’ll do it forwards and backwards with your eyes open and closed. OK? All right great.

So now we’re gonna test her balance. We like to challenge their balance by having them do a tandem gait forwards and backwards with their eyes open and their eyes closed. Each step of the way gets a little bit more challenging, and is able to provoke more problems with kids who have concussion. And you’ll be able to identify them if they have balance difficulty.

Please note that kids with concussion, may have very poor balance. And so be aware that you’re near them, or nearby so that if they lose their balance, you can help steady them so that they stay safe.

All right Ava we’re going to walk in a tandem gait, heel toe, heel toe, eyes open going forward. And then I’ll tell you when to close your eyes. Go ahead. Great, so you can see she’s doing a great job. Now close your eyes. She has no sway. She’s keeping her hands by her side. Open your eyes and stop. Now we’re going to go backwards, eyes open. And this is a little bit more difficult than going forwards. And then closing your eyes is the most difficult part of all. Great, you can stop.

So a lot of our kids, when they have an acute concussion will have trouble with any of these maneuvers. Sometimes they’ll sway back and forth, sometimes they’ll have their arms go up from their sides to help them maintain their balance. And sometimes they’ll step off the tandem gait line because they’re not able to maintain their balance.

So that concludes the pediatric history and physical for the concussion. Thanks for joining us, and thanks to Ava for contributing and participating with us on this.